Section 926.10  Authority (Repealed)

 

(Source:  Repealed at 43 Ill. Reg. 3246, effective February 25, 2019)

 

Section 926.20  Purpose and Scope

 

a)         The purpose of this Part is to establish guidelines for the handling of complaints received by the Department of Insurance against insurers, insurance producers or any other entity or individual licensed, registered, certified, or granted a Certificate of Authority as described in this Section.  This Part also sets forth minimum complaint recordkeeping requirements.

 

b)         This Part applies to any insurance company licensed to do business in this State that is transacting the kind or kinds of business described as Class 1, Class 2, or Class 3 in Section 4 of the Code.  This Part also applies to any entity or individual that the Director of Insurance licenses, registers or grants a Certificate of Authority under Chapter 215 of the Illinois Compiled Statutes.

 

(Source:  Amended at 47 Ill. Reg. 2294, effective February 1, 2023)

 

Section 926.30  Definitions

 

"Code" means the Illinois Insurance Code [215 ILCS 5].

 

"Complaint" means any written communication primarily expressing a grievance.

 

"Department" means the Illinois Department of Insurance.

 

(Source:  Amended at 43 Ill. Reg. 3246, effective February 25, 2019)

 

Section 926.40  Complaint Handling Procedure

 

a)         Notification and Response Requirements

When the Department receives a complaint against an entity or individual identified in Section 926.20 (respondent), and the Department determines that the complaint falls under its authority to investigate, the Department will notify the respondent of the complaint.  The Department will, in its notification, specify the date when a report is to be received from the respondent, which, in most instances, will be 21 calendar days after notification is sent to the respondent.

 

b)         Contents of Response or Report or Both

 

1)         Each respondent shall supply adequate documentation that explains all actions taken or not taken and that were the basis for the complaint;

 

2)         Documents necessary to support the respondent's position, or information requested by the Department, shall be furnished with the respondent's reply; and

 

3)         The Department will respect the confidentiality of medical reports and other documents that, by law, are confidential.  Any other information furnished by a respondent shall be marked "confidential" if the respondent does not wish it to be released to the complainant.

 

c)         Follow-up or Conclusion

Upon receipt of the respondent's report, the Department will evaluate the material submitted and advise the complainant of the action taken.  Possible actions include but are not limited to the following:

 

1)         Close the complaint file;

 

2)         Pursue further investigation with the respondent or complainant; or

 

3)         Refer the complaint file to the appropriate Division within the Department for further regulatory action.

 

d)         The Department deems complaint files to be confidential records and will not release them to persons other than the complainant and the respondent.

 

(Source:  Amended at 47 Ill. Reg. 2294, effective February 1, 2023)

 

Section 926.50  Maintenance of Complaint Records

 

Insurance companies to which this Part applies shall maintain records containing the minimum information as outlined in Exhibit A and as defined in Exhibit B of this Part.  The complaint record shall be kept on a calendar year basis and shall be maintained for 7 years after the complaint has been closed, and shall apply to complaints received from the Department, as well as those received directly from the consumer by the company.

 

(Source:  Amended at 23 Ill. Reg. 5695, effective May 3, 1999)

 

Section 926.60  Severability Provision (Repealed)

 

(Source:  Repealed at 23 Ill. Reg. 5695, effective May 3, 1999)

 

Section 926.70  Effective Date (Repealed)

 

(Source:  Repealed at 23 Ill. Reg. 5695, effective May 3, 1999)

Section 926.EXHIBIT A   Complaint Record

 

 

COMPLAINT RECORD

 

Column A	Column B	Column C	Column D	Column E	Column F	Column G	Column H
Identification Number	Reason Code	Coverage Code	Disposition after Complaint Receipt	Date Received	Date Closed	Insurance Department Complaint	State of Origin

 

(Source:  Amended at 43 Ill. Reg. 3246, effective February 25, 2019)

Section 926.EXHIBIT B   Explanation

 

Column

 

A.        Identification Number.  As noted, this refers to the identification number of the complaint.

 

B.        Reason Code.  Complaints are to be classified by the nature of the complaint within one of the involved company's functions of underwriting, marketing and sales, claims, policyholder service, and miscellaneous.  The following is the classification required for each function:

 

1)         Underwriting

 

a)         Company underwriting

 

b)         Individual's application underwriting (this refers to any complaint regarding misrepresentations or declarations in the application for insurance that resulted in company action involved in the complaint)

 

c)         Cancellation

 

d)         Recission

 

e)         Non-renewal

 

f)         Premiums and rating

 

g)         Delays

 

h)         Refusal to insure

 

i)          Miscellaneous (not covered by B(1)(a) through (h))

 

j)          Creditable coverage re:  Health Insurance Portability and Accountability Act (HIPAA)

 

k)         Late enrollee (HIPAA)

 

l)          Special enrollment (HIPAA)

 

m)        Renewability (HIPAA)

 

2)         Marketing and Sales

 

a)         General advertising

 

b)         Mass marketing advertising  (advertising that is essentially directed to reach more people than in a one-to-one relationship)

 

c)         Insurance producer handling

 

d)         Replacement

 

e)         Delays

 

f)         Alleged misleading statement or misrepresentation

 

g)         Miscellaneous (not otherwise covered by this B(2))

 

3)         Claims

 

a)         Claims procedure

 

b)         Delays

 

c)         Unsatisfactory settlements

 

d)         Natural disaster adjusting (hurricane, flood or other situations that produce a large number of claims)

 

e)         Unsatisfactory settlement offers

 

f)         Denial of claim

 

g)         Miscellaneous (not otherwise covered by this B(3))

 

4)         Policyholder service

 

a)         Failure to respond

 

b)         Delays

 

c)         Return of premium

 

d)         Miscellaneous (not covered by B(4)(a) through (c))

 

e)         Continuation – State or federal

 

5)         Miscellaneous

 

C.        Coverage Code.  Complaints are to be classified according to the line of insurance involved, as follows:

 

1)         Automobile – Personal

 

2)         Automobile – Commercial

 

3)         Homeowners – Farmowners – Mobile or Manufactured Homeowners – Dwelling

 

4)         Commercial Property

 

5)         Inland Marine

 

6)         Individual Life

 

7)         Group Life

 

8)         Annuities

 

9)         Individual Health – Accident & Sickness (including PPO)

 

10)         Group Health – Accident & Sickness (including PPO)

 

11)         HMO individual or group

 

12)         Limited Health Service Organizations (LHSO)

 

13)         Workers' Compensation

 

14)         General/Professional liability

 

15)         Miscellaneous (not otherwise covered by this C)

 

D.        Company Disposition After Complaint Receipt.  The complaint record shall note the disposition of the complaint.  The following examples are recommended, but are not intended to be required language nor to exhaust the possibilities.  These examples are taken from the form used by the Department of Insurance.

 

1)         Corrective action was taken

 

a)         Rate problem resolved

 

b)         Cancellation withdrawn

 

c)         Non-renewal rescinded

 

d)         Policy restored (Life/A & H)

 

e)         Policy issued

 

f)         Premium refunded

 

g)         Additional monies paid (claims)

 

h)         Coverage extended (claims)

 

i)          Claim reopened

 

j)          Claim settled

 

k)         Cash surrender paid

 

l)          Referral approved

 

m)        Provider changed

 

2)         No action was deemed necessary

 

a)         Contract provisions

 

b)         Questions of fact

 

c)         Policy not in force

 

d)         Cancellation upheld

 

e)         Non-renewal upheld

 

f)         Return premium correct

 

g)         Insufficient information (from complainant)

 

3)         Information was furnished to complainant

 

E.         Date Received.  This refers to the date the complaint was received by the insurer.

 

F.         Date Closed.  This refers to the date on which the complaint was disposed of by the insurer, whether by one action or a series of actions.

 

G.        Insurance Department Complaint.  Complaints are to be classified so as to indicate if the origin of the complaint was from an insurance department.

 

H.        State of Origin.  The complaint record shall note the state from which the complaint originated.  Ordinarily, this will be the state of residence of the complainant.

 

(Source:  Amended at 43 Ill. Reg. 3246, effective February 25, 2019)